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"A" Definitions
Access - The ability to see providers of healthcare services and facilities where care is given.
Accreditation - The process used to certify and recognize that a predetermined set of standards has been met.
Administrative Costs - The general overhead expenses of operating a business. Examples include office space, supplies, equipment maintenance, etc. These expenses are not directly related to the cost of healthcare and related services.
Admitting Physician - The doctor responsible for admitting a patient to a hospital or other inpatient health facility, and in many cases, coordinating a patient's medical care during their stay.
Adverse Selection - Attracting individuals who have more health related problems or illness than the general population to sign up for coverage under one health plan over another health plan. Specifically, individuals who are sicker than the insurer anticipated when developing the rates of reimbursement for medical costs.
Allowable Expense - The maximum dollar amount for covered healthcare expenses that a third party will reimburse for a service or item when a claim is made.
Alternate Facility - A non-hospital healthcare facility that provides one or more of the following on an outpatient basis: surgical services, emergency health services, rehabilitative services, laboratory or diagnostic services; or provides on an inpatient or outpatient basis: mental health or chemical dependency services. The facility may include an attachment to a hospital but does not include a doctor's office.
Ambulatory Care - All types of health services that are provided on an outpatient basis in contrast to services provided in the home or to someone while admitted to a hospital stay.
Amendment - A description of additional provisions attached to a contract. An amendment is valid only when signed by an officer of a healthcare insurance company.
Ancillary Services - Professional services in a hospital or other inpatient health program. These may include x-ray, drug, laboratory, or other services.
Appeal - An oral or written request to change a decision regarding a grievance already ruled upon.
Appendix - An attachment at the end of a contract. It adds to certain provisions of the contract. The appendix is valid only when signed by the party offering the contract.
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"B" Definitions
Benchmarking - The identification of best practices in your own or another industry that show superior performance.
Benefit Package - A group of healthcare services that a health plan offers to provide under the terms of a contract to a group or single individual.
Benefits -The coverage of healthcare services and related items provided under the terms of a contract.
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"C" Definitions
Cafeteria Plan - In the healthcare context, an employee benefit plan where the employee has the option to select among various types of healthcare plans such as traditional indemnity, catastrophic coverage, or managed care benefits plan. Usually, there is some type of cost-sharing between the employee and their employer.
Calendar Year - January 1 through December 31 of any given year.
Case Management - A process used to manage the care of a covered person when specific healthcare needs are identified. The goal is to provide the highest quality care in an efficient and effective manner for the benefit of the patient receiving treatment.
Case Manager - A health professional working with or for a health plan that is responsible for coordinating the healthcare and related services of a person insured by the health plan.
Certificate of Coverage - A legal description of the benefits included under, and to be provided by, a health plan when a certificate of coverage is required by law.
Chemical Dependency - The need to rely on alcohol, chemicals, or drugs for support.
COBRA - Consolidated Omnibus Budget Reconciliation Act of 1985 - A federal law that requires employers to offer continued health insurance coverage to specific employees and their dependents who have had their group health insurance coverage terminated. This Act applies to employers with 20 or more eligible employees.
Coinsurance - The part of the healthcare cost that a covered person has to pay out of their pocket for any care received according to the terms of their healthcare contract. (Also see copayment, deductible and cost sharing).
Complaint - An oral or written statement of dissatisfaction with a health plan or with health services provided through the health plan.
Confinement/Confined - Referring to inpatient care, it is an uninterrupted stay following formal admission to any hospital, skilled nursing facility or alternate facility.
Contract - An agreement between a healthcare plan and an enrolling group, which states the conditions between the parties involved as well as benefits and exclusions. Furthermore, the contract charge is the premium that all subscribers and enrolled dependents must pay for the benefits of the contract.
Contract Year(s) - The time period between the effective date and the expiration date of a contract. A contract year may not be a full year in some cases and may be renewed annually according to the renewal date stated in the contract application.
Conversion Privilege - A provision in some group health plans that allows a covered person the right to convert to an individual insurance policy provided that they leave the group plan.
Coordination of Benefits - The coordination of claims handling by primary and secondary insurance carriers to ensure that any person with duplicate coverage does not receive more than 100% reimbursement for any healthcare costs.
Copayment or Copay - In addition to the premium and according to a contract, a copay is the dollar amount (either a percentage or specified dollar amount) that a covered person must pay for healthcare services at the time that the services are rendered. A copayment may be either a dollar amount or a percentage of eligible expenses for items such as physician office visits, prescriptions or hospital services.
Cosmetic Procedure - Any procedure that improves physical appearance without being medically necessary or without correcting a physical function.
Cost Sharing - Another term for the costs that a covered person must pay for any healthcare service according to the specifications of the healthcare insurance plan and benefits. (Also see coinsurance, copayment and deductible).
Coverage or Covered - The fact that the healthcare services provided to an insured person will be paid by the insurance company according to the terms, conditions, limitations, and exclusions of the contract. Payment will occur provided that the services are rendered when that contract is in effect.
Covered Person or Member - In reference to either a subscriber or an enrolled dependent, a covered person is one who both meets the eligibility requirements of the contract and is enrolled for coverage under the contract.
CPT (Current Procedural Terminology) - A list of physician or provider services and/or procedures which are each represented by a 5 digit code. These codes have become a nationwide dialect for services and procedures within the healthcare industry.
Credentialing - The process by which the health plan or a third party obtains, reviews, and verifies the experience, certifications, and training of any provider who applies for participation in their health plan before accepting that provider.
Custodial Care - Non-health-related services, such as assistance in activities of daily living or health-related-services, that do not seek to cure a medical condition or are provided when the medical condition of the patient is not changing. Custodial Care does not require administration by skilled licensed medical personnel.
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"D" Definitions
Date of Service - The date when a covered person is provided with a healthcare service.
Deductible - An amount that a covered person, according to their contract, must pay for services rendered, items furnished, or for a period of time before insurance coverage benefits begin. (Also see coinsurance, copayment and cost sharing).
Dental Care - All services provided by or under the direction of a dentist. Such services include: the care of teeth and the surrounding tissues; correction of an overbite or underbite; any surgical procedure that involves the hard or soft tissues of the mouth.
Dentist - Any doctor of dental surgery, "DDS," who is licensed and qualified to provide dental care under the law of jurisdiction in which treatment is received.
Dependent - A person who relies on a spouse, parent, grandparent, legal guardian, or one with whom they reside, for healthcare insurance. The definition of dependent is subject to differing conditions and limitations between healthcare plans.
Designated Transplant Facility - A hospital or alternate facility that has entered into an agreement either with or on behalf of a health plan to provide health services for covered transplants.
Disenrollment - The process of terminating the benefits or coverage of persons or groups.
Doctor - Any doctor of medicine, "M.D.", or doctor of osteopathy, "D.O.", who is licensed and qualified under the law of jurisdiction in which treatment is received.
Drug Formulary - A list of prescription drugs that are approved for use and covered by an insurance plan. These prescriptions may be dispensed to covered persons at participating pharmacies. The formulary is subject to review and change.
DSM - The Diagnostic and Statistical Manual of Mental Disorders.
Dual Choice - An option offered by an employer that permits covered persons to choose between two health plans.
Duplicate Coverage Inquiry - When one insurance company or medical plan contacts another to ask if a covered person has other insurance coverage. If the covered person does, then the insurance companies must coordinate their benefits.
Durable Medical Equipment (DME) - Equipment which is used for medical purposes, that can be reused, is generally useful only in the presence of sickness or injury and can be used in the home. Some examples include oxygen equipment, hospital beds, and wheelchairs.
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"E" Definitions
Electronic Data Interchange (EDI) - The exchange of information between two or more organizations through the use of computer-to-computer electronic transmission.
Eligible Expenses - Reasonable and customary charges for healthcare services incurred while coverage is in effect.
Eligible Person - A person who is eligible for benefits under a healthcare plan and meets the eligibility requirements specified in the contract.
Emergency - An accidental or unexpected injury or health condition that requires immediate care or treatment in order to avoid risking the life or health of the person being treated.
Emergency Health Services - Any health service used in the treatment of an emergency.
Enrolled Dependent - A dependent who is enrolled for coverage under the health plan's contract.
Enrollee - A person who is directly or independently eligible for coverage of health services provided under a health plan contract on their own behalf (not by being a dependent).
Enrolling Group - An employer or other group with whom an insurer has made a health plan contract.
Enrollment - Either the process of signing up individuals or groups for membership with a health plan or the total number of covered individuals by a health plan.
ERISA - The Employee Retirement Income Security Act of 1974.
Evidence of Insurability - The information obtained through medical examinations or written statements about a person's health. This information may determine insurance coverage rates by identifying existing health conditions. Also, the information or proof of health is usually a requirement for those that apply for excess life insurance.
Exclusions - Health services not covered under an insurance plan.
Experience Rating - The process of setting insurance rates according to previous claims utilization of certain services by a group(s) of covered individuals.
Experimental, Investigational or Unproven - Any healthcare services, products, or procedures considered by a health plan or government agency to be ineffective, unreasonable, unnecessary, or not proven effective through scientific research.
Explanation of Benefits (EOB) - A statement of coverage sent to covered persons which lists any health services that have been provided as well as the amount billed and payment made by the health plan for those services.
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"F" Definitions
FDA - The Food and Drug Administration.
Fee-for-Service (FFS) - The amount billed, according to a set fee schedule, by healthcare professionals to either a patient or a healthcare insurance company for services rendered to the patient.
Fiscal Soundness - The required amount of funds that a managed care organization must keep on reserve due to financial risk, as regulated by the Department of Insurance.
Flexible Spending Account - A way for covered persons to use pre-tax dollars, money set aside from their salary that may be reimbursed, to pay for any healthcare services not covered under the terms and conditions of their contract.
Formulary - (See drug formulary).
Full-time Student - Any person enrolled in a study program, whether it be high school, college or vocational school, that is considered a full time attendant by that institution. Age limit restrictions may apply.
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"G" Definitions
Generic Drug List - A list of prescription medications that are sold at a generic product level and are covered by a health plan. This list varies according to the insurer and is subject to review and change.
Genetic Screening or Testing - Any laboratory test that is used to directly detect abnormalities, defects, or deficiencies in human genes or chromosomes.
Grievance - Any complaint or request for change made by a covered person regarding a decision made by an insurance company.
Group Contract - An agreement made between a health plan and a subscribing employer group which specifies all terms and conditions of the plan. This contract is generally limited to one year and may be available for renewal thereafter.
Guidelines, Practice Parameters, and Practice Pattern Guidelines - Rules and regulations intended to set a standard of practice and treatment for healthcare providers.
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"H" Definitions
HCFA - HealthCare Financing Administration.
HCFA 1500 - An HCFA form used by healthcare providers to bill insurance carriers for services rendered.
Health Insurance Portability and Accountability Act of 1996 (HIPAA) - This act established the federal law that group insurance plans must not discriminate based on health status and insurance renewability.
Health Maintenance Organization (HMO) - An insurer that provides or arranges the coverage of health services for their members for a set prepaid premium. Four kinds of HMOs include the group model, the individual practice association, the network model, and the staff model. Physicians Health Plan is an open access network model.
Health Savings Account (HSA) - An account allowing employees to pay for current healthcare expenses and save for future qualified medical and retiree healthcare expenses on a tax-free basis. An individual must be covered by a high deductible health plan to be eligible for an HSA.
Health Services - Any services or supplies covered under a contract that are used in the maintenance of health or treatment of disease.
HEDIS (Health Employer Data and Information Set) - A basic set of measures set by the National Committee for Quality Assurance to determine the performance of a health plan as well as setting standards for the quality of care given by managed care organizations. This set is like the "report card" of healthcare and holds plans accountable for their performance.
High Deductible Health Plan (HDHP) - A health insurance plan designed to save on insurance premium costs, with a minimum deductible of $1,200 (self-only coverage) or $2,400 (family coverage). The annual out-of-pocket, including deductibles and co-insurance, does not exceed $5,000 (self-only coverage) or $10,000 (family coverage).
Home Health Agency - A program or facility that is lawfully authorized and certified to provide healthcare services in the home.
Hospital - A twenty-four hour facility that is operated in accordance with the law and which is primarily focused on the treatment and care of injuries and sickness, usually on an inpatient basis.
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"I" Definitions
ICD - The International Classification of Diseases of the United States Department of Health and Human Services.
Indemnity - A benefit plan where a covered person is reimbursed dollars spent, according to a contract, for any covered healthcare services rendered.
Indemnity Carrier - An insurer that offers coverage under contract and, after the review of claims, reimburses its covered persons for money spent on healthcare services.
Indemnity Insurance - The traditional form of health insurance where the physician bills the patient rather than their insurer for reimbursement or payment to the physician.
Infertility - A condition whereby an otherwise healthy person is documented as unable to conceive after one year of unprotected sexual intercourse.
Initial Open Enrollment Period - The first time that eligible persons may enroll themselves and any dependents under a contract for insurance benefits.
Injury - Any bodily damage, other than sickness, and its related conditions or symptoms.
Inpatient - A person who is registered as a bed patient in a hospital and receives physician services for at least twenty-four consecutive hours.
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"J" Definitions
There are currently no listings for the letter "J"
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"K" Definitions
There are currently no listings for the letter "K"
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"L" Definitions
Length of Stay (LOS) - During one admission, the number of days that a person stays in an inpatient facility counting the admission day but not the day of discharge.
Long-Term Care (LTC) - The care for those that either have a chronic disease or those individuals in need of non-medical care for an extended period of time. Some examples include nursing homes and home care.
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"M" Definitions
Managed Care - A system of healthcare that allows its membership access to quality and cost-effective healthcare; that influences the utilization and cost of services; that emphasizes preventive healthcare; and takes on the financial risk that would otherwise be passed on to the patient and payer. This system is often associated with HMOs and PPOs.
Mandated Benefits - The benefits that are required by law to be included in health plan contracts.
Medicaid - Grants to states for medical assistance programs of the United States Social Security Act. These programs provide healthcare to the undeserved. The program guidelines vary from state to state.
Medical Director - A licensed physician that is contracted by an insurer to provide medical review of health services that are proposed or rendered for eligible and/or covered persons.
Medical Underwriting - A way for insurance companies to rate the risk of insuring certain individuals or group applicants. The degree of risk then establishes premiums or the denial of coverage.
Medically Necessary - Any healthcare services that are necessary, as determined by the medical community, in the prevention of harm or adverse effects as well as the maintenance of health. These services must be cost-effective and show medical value in that particular service. More often than not, non-medically necessary procedures are not covered under insurance plans.
Medicare - A program under the United States Social Security Act that provides healthcare to those over the age of 65 as well as the disabled. There are two parts to this program: Medicare Part A and Medicare Part B. Part A is paid from federal taxes and covers the cost of hospitalization and short-term nursing care. Part B, or Supplementary Medical Insurance, is voluntary and requires a monthly premium which is deducted from Social Security Payments and covers most of the cost of physician and non-hospital care.
Member or Covered Person - In reference to either a subscriber or an enrolled dependent, a member is one who both meets the eligibility requirements of the contract and is enrolled for coverage under the contract.
Member Month - For each member, the recorded count of the months that the member is covered.
Members Per Year - The number of members eligible for health plan coverage on a yearly basis.
Mental Health Parity - The idea that mental healthcare is covered in the same way as physical healthcare.
Mental Illness - Any condition that has an emotional origin or effect. Alcoholism or chemical/drug dependencies are not included.
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"N" Definitions
Non-Participating Provider - Any provider who is not contracted with a health plan to be a participating provider of healthcare services.
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"O" Definitions
Open Access - An arrangement that allows covered persons access to specialty care from participating physicians without referrals or prior authorizations.
Office Visit - Seeing a provider or physician in an office setting for services.
OHTA - Office of Health Technology Assessment.
Open Enrollment Period - After the initial open enrollment period, the time where eligible persons may change health or benefit plans usually without evidence of insurability or waiting periods. This period of time usually occurs annually.
Ophthalmologist - A trained and licensed medical doctor who specializes in treating conditions and diseases of the eye.
Out of Area - A reference to services that are outside a certain geographic area generally referred to as the service area.
Out of Area Coverage - Coverage of benefits in an area that would normally be outside the health plan's coverage service area.
Out of Area Services - When covered persons receive services outside of the normal coverage area. These services are usually only covered in cases of emergency or when prior approval is given, unless otherwise stated in the contract.
Outcome - The result of treatments or medical programs in terms of failure or success.
Out of Network Items and Services - Healthcare coverage for a person who elects to receive care from a non-participating provider when covered under the contract. In these cases, the deductible or copayment may be higher.
Out of Pocket Costs/Expenses - Any payments for healthcare services made directly by a covered person. Examples include copayments and deductibles.
Out of Pocket Limit or Maximum - The maximum amount of expenses, as set by a healthcare plan, that a person is obligated to pay directly during each calendar year.
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"P" Definitions
Par or Participating - Refers to the status of a provider of products or services being in a service agreement with a health plan or insurer.
Par Mail Order Drug Provider - A prescription medication vendor who has a contract or service agreement with a health plan in order to provide medications to the plan's members via mail order.
Par Pharmacy - A pharmacy who has a contract or service agreement with an insurer in order to provide medications to the plan's members directly.
Par Prescriber - A participating provider who is licensed to prescribe drugs to patients.
Participating Provider - A provider of healthcare, such as a doctor or hospital, who has entered into a contract or service agreement with an insurer in order to provide healthcare to the plan's members.
Peer Review - An evaluation of one doctor by other doctors usually of the same practice or service area.
Per Member Per Month (PMPM) - A formula that produces the total cost or revenue derived from each covered member enrolled in the health plan each month.
Placement for Adoption - The assumption that one waiting for the adoption of a child has a legal obligation to the financial support of that child.
Point of Service Plan - A health plan that allows its members to choose between participating and non-participating providers with the condition that benefit levels may differ between the two options.
Practice Guideline - Also called Clinical Practice, these are the standards of health services that must be followed by doctors or other providers as set by the government or a group of doctors.
Pre-Admission Certification (PAC) - The review of a patient's need for inpatient hospital care prior to admission. Under health plans that require PAC, this certification is a prerequisite for payment.
Pre-Existing Condition - Any health problem or illness that exists prior to the coverage of health insurance. This condition can cause higher premiums, the exemption of the condition, under some types of insurance policies, or the denial of coverage all together.
Pregnancy - The development of offspring in the uterus. Insurance coverage of this condition could include prenatal and postnatal care, childbirth, and complications of pregnancy.
Premium - A fee charged to plan subscribers and enrolled dependents that are covered under the contract for the insurance coverage provided. This fee is generally shared by the insured and their employer.
Prescription - An authorization for a prescription medication given by a participating prescriber.
Prescription Drug - Any medication that is approved by the FDA and, by law, requires a prescription.
Prescription Order or Refill - The dispensing of a prescription medication by a participating pharmacy as ordered by the prescriber.
Preventive Care or Services - Healthcare that emphasizes health maintenance and the prevention of disease through measures such as routine physical exams and immunizations.
Primary Care Physician (PCP) - A physician whose primary practice focus is internal medicine, family/general practice, OBGYN, and pediatrics. They generally provide treatment of routine illness and injuries and focus on preventive healthcare.
Primary Care - The initial and nonspecialized healthcare services that a covered person receives from a provider in the fields of Family Medicine, Internal Medicine, Obstetrics or Pediatrics.
Primary Plan/Secondary Plan - The primary plan includes benefits which are considered before any other healthcare plan for services rendered. The secondary healthcare plan assumes responsibility of payment for charges not covered by the primary plan as defined under their contract.
Prior Authorization - The review and approval of healthcare or specific services by an insurer prior to coverage. Prior authorization is needed before health services are received under most health plan contracts.
Prior Carrier Deductible Credit - A benefit which allows covered persons and/or their dependents credit for deductibles already accumulated for the calendar year under their employer's previous health insurance program. The amount of deductible met under the covered person's prior insurance for the same calendar year can be applied toward their new deductible requirement.
Provider - Any licensed physician or institution that provides healthcare services.
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"Q" Definitions
Qualified Medical Child Support Order (QMCSO) - A medical child support order that requires parents to provide health coverage for their children.
Quality Assurance - A program designed to review and positively affect the quality of care given by a healthcare provider. This program includes activities such as peer review, utilization review, and education.
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"R" Definitions
Rate - The amount of money paid to an insurer for medical coverage during each enrollment period.
Rating Process - The determining of the premium rate in accordance to the risk presented by the group or individual being evaluated for insurance. Some examples of determinants are age, sex, location, average family size and administration costs.
Reasonable and Customary Charge - The charges or fees that are common within a geographic area. These fees are reasonable if they are within the average charge for service parameters for that area, and if the charges for participating providers are what have been contracted with the health plan.
Reconstructive Surgery - Any surgery used in the restoration of any part of the body in order to obtain its original function.
Referred or Referral - A participating provider's written request to have a covered person receive benefit coverage for services rendered by a non-participating provider as well as the insurer's written approval for such request.
Reinsurance - The process by which one insurance company takes out insurance under another insurance company in order to protect itself against financial risks incurred through the honoring of claims.
Rescue Procedures - The procedures of removing blood from a body and then returning that blood to the same body, as well as removing blood from one body and infusing it into another body.
Rider - A description of covered health services that is attached to a health plan's contract.
Risk - The possibility of loss.
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"S" Definitions
Second Opinion Policy - A policy that allows a covered person to consult with two participating providers prior to scheduling a service.
Self-Funding or Self-Insurance - The process by which an employer funds their own benefit plans without purchasing insurance from a third party.
Semi-Private Room - A room in a hospital, nursing facility or alternate facility that contains two or more beds.
Service Area - The geographic area within certain boundaries that is approved for providing service to a health plan's members.
Sickness - Any physical illness, disorder or disease including pregnancy but not mental illness.
Skilled Nursing Facility - Any facility, either freestanding or part of a hospital, that has been certified by Medicare to care for patients that require less intense care than that of a hospital. Another term for this entity is an extended care facility.
Small Employer - Any entity that is active in business and that employs at least two, but not more than fifty, eligible employees (those who work full-time).
Sound Natural Teeth - Teeth that are (1) free of active or chronic clinical decay; (2) have at least 50% bony support; and (3) are functional in the arch.
Specialist - Any health professional who has specific training and certification in a particular area of medical care.
Subrogation - The process by which an insurance company can recover from third parties some or all of the benefits that were paid for services received by a covered person.
Subscriber - An individual that is enrolled for coverage under a contract and who is responsible for payment of premiums or whose employment is the basis for membership.
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"T" Definitions
Third Party Administrator (TPA) - An independent person or corporate entity, other than the employee benefit plan or healthcare provider, that administers group benefits, claims, and administration of a self-insured company or group.
Turnaround Time - The number of days from the receipt of a claim to the payment of that claim.
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"U" Definitions
Unbundling - The billing of each component of a medical service or procedure separately. This can often result in higher overall costs.
Underwriting - The review and assessment of possible new sales and renewing group cases for pricing, risk control, and feasibility.
Urgent Care - The treatment of unexpected sickness or injuries that are not life threatening but require immediate attention.
Urgi-Center - A licensed medical center that provides urgent care.
Usual, Customary and Reasonable - (See reasonable and customary charge).
Utilization - The measurement of how often a particular benefit is used within a health plan's covered member population.
Utilization Review - A formal review of the necessity and appropriateness of healthcare services and treatment plans.
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"V" Definitions
There are currently no listings for the letter "V"
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"W" Definitions
Worker's Compensation - A system that compensates employees for any work-related injuries in order to avoid lawsuits against their employers.
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"X" Definitions
There are currently no listings for the letter "X"
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"Y" Definitions
There are currently no listings for the letter "Y"
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"Z" Definitions
There are currently no listings for the letter "Z"
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